Hemorrhagic Stroke

Question 1

The incidence of cerebral hemorrhage is roughly equally divided between….

Answer 1

• Bleeding around the brain
• Subarachnoid hemorrhage
• Bleeding into the brain, parenchymal, or intracerebellar

Question 2

80% of Subarachnoid Hemorrhages are caused by

Answer 2

Berry Aneurysm rupture.

Question 3

Berry Aneurysms of what size tend to rupture?

Answer 3

Over 5mm

Over 20% of the population has an aneurysm measuring less than 2mm in diameter. These rarely rupture

Question 4

Risk factors for SAH

Answer 4

• tobacco
• alcohol
• htn
• oral contraceptives
• low cholesterol
• Genetics (polycystic kidney disease, marfan

Question 5

Symptoms of SAH

Answer 5

• sudden severe headache, worst of my life
• rapid loss of consciousness
• neck stiffness, pain, photophobia
• Nausea
• Focal neurologic signs frequntly absent

Question 6

What helps to differentiate SAH from ischemic stroke?

Answer 6

Lack of neurologic symptoms…This is because there is no injury inside the brain parenchyma at this point.

Question 7

Other signs of SAH

Answer 7

• Abnormal vital signs like high BP or arrhythmias (due to breakdown products from RBCs that irritate the brainstem centers for regulating heart rate)
• Subtle neuro signs like CN III paresis
• Paraparesis (bilateral leg weakness) suggests potential aneurysm of anterior cerebral
• Hemiparesis (weakness on one side of body) suggests potential MCA aneurysm

Question 8

Most important diagnostic test to reveal SAH

Answer 8

NON-Contrast CT

Question 9

When may a CT scan be negative in a pt with an SAH

Answer 9

• When the bleeding is slight or the scan is delayed for several days.

Question 10

If the CT is negative and you still suspect SAH, whats next

Answer 10

Lumbar puncture

Question 11

What is the only method to 100% rule out a subarachnoid bleed

Answer 11

lumbar puncture

Question 12

Lumbar puncture in SAH technique? KNOW!!!

Answer 12

Must delay the onset of the lumbar puncture 4 hours after the headache starts. THis will allow time for some of the RBS’s to lyse and release their contents (hemoglobin). THis will help you differentiate between blood cells that entered the CSF when you nicked a vein performing the spinal tap versus blood from an aneurysm. Must centrifuge the blood immediately because blood from a nicked vein will centrifuge to the bottom and leave the supernatant clear.

Question 13

How do you tell where the aneurysm is?

Answer 13

MRI will revela aneurysms over 5mm.

• GOLD STANDARD: 4 vessel digital subtraction arteriogram.

Question 14

Treatment for SAH

Answer 14

Definitive therapy for Berry aneurysm is the placement of small coils within the aneurysm through an intrarterial catheter. to cause the aneurysm to clot and itself

Question 15

Most common cause for parenchymal hemorrhage?

Answer 15

Brain Trauma
HTN
Arteriovenous malformations

-trauma is most common

Question 16

What kind of aneurysms does HTN lead to

Answer 16

Charcot Bouchard aneurysms that eventually rupture.

Question 17

Where do Charcot Bouchard aneurysms usually arise

Answer 17

lenticulostriate vessels

Question 18

Hypertensive bleeds generally occur where?

Answer 18

• Basal Ganglia
• Thalamus
• Pons
• Cerebellum

Question 19

AVM (arteriovenous malformation) hemorrhage treatment

Answer 19

• Intravascular occlusion of AVM with coils followed by surgical removal or obliteration of AVM

Question 20

50% of cerebral hemorrhages are

Answer 20

subarachnoid in nature….the other 50 are parenchymal

Question 21

Regarding subarachnoid hemorrhages, CNIII paresis (down and out eye) with pupil dilation and ptosis (lid lag) usually means what

Answer 21

You have a berry aneurysm at the junction of the PCOM and Internal carotid. Lies right on top of the optic tract.

Question 22

Regarding subarachnoid hemorrhages, Paraparesis (bilateral leg weakness) means what

Answer 22

aneurysm of the anterior cerebral artery

Whereas hemiparesis generally means middle cerebral artery aneurysm

Question 23

xanthochromia

Answer 23

yellow discoloration of spinal fluid that becomes present a couple days after a subarachnoid hemorrhage due to breakdown of hemoglobin/

Question 24

What if you do a lumbar puncture and the CSF becomes progressively clearer as you take samples

Answer 24

The blood in the CSF is most likely a result of a nicked vein.